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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street,Stockton,California 95202 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> C Facility Name W C_D A m QM Phone# 205 %15- (61064- <br /> � Address 10 p S M A i N ST KE E T M A NY E C A 95-5-54 <br /> T Cross Street t N DU S�SLI k L_ K�114 wme <br /> Y Owner/Operator K Ptd t,3 R Q N Ai Z Phone# (2 oq) S l0c,-- 4 00 3 <br /> o Contractor Name 9,E L(A Ll: 7 EZ(ZpL E t1 Phone# 2 O q � S_ S j S b <br /> T Contractor Address 2 >�R Ih1 IRON 5Z{LEET DAitDALti; CALic# $ '3-jpb Class n, <br /> A Insurer (aj C E 1J V kg o V4 Ill em?a L Work Comp# <br /> T ICC Technician's Certification Number --505 j (� Expiration Date /,pp j t-) <br /> o ICC Installer's Certification Number Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approved approved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A y' z/z 7 Lo et <br /> N Plan Reviewers Name / r� /y" ' l �2"Z� Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORM C OF THE W FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Signature i J—��Title��' Date / 7 �W <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the <br /> tbilling <br /> 1b5y signature and date below. <br /> NAME I-ULat S fT Afl-NM R TITLE MBF- PHONE#(�lol4bw��-31 I <br /> ADDRESS IkOO S, MAIO STrLEET , MANILLA R 9 S1>"S 1- <br /> SIGNATURE V, <br /> -SIGNATUREV, <br /> EH230038(revised 12/31/07) <br /> 1 <br />